Is the AMA Irrelevant or the Main Player?

Writing (and editing) books is hard, even with multiple authors. Been there; done that. Fiction and non-fiction alike remain vital methods of communication, even after predictions that the internet would weaken their importance. The internet made it far easier to do the research to turn into books. Moreover, the internet's use by visionary entrepreneurs to sell books (and later virtually everything) greatly diminished independent and small bookstores. Of course, computers made the self-published book (often with no peer review, editing, fact-checking, or copy editing) a major industry. More books are now being published than ever before. Books sold and read, however, is an entirely different matter.

In the pre-internet era, author Paul Starr, Princeton Professor of Sociology and Public Affairs, researched 220 years of literature to compile the data and references needed to inform a nearly 600-page volume called The Social Transformation of American Medicine.

In 1983, The New York Times called the book a "monumental achievement." It won numerous major literary awards, including the Pulitzer Prize, and has been undiminished by competition for nearly 40 years. If you ask 10 knowledgeable historians why American medicine is as it is in 2022, you may get 10 different answers. Viewpoints will depend in part on whether those experts are political scientists, economists, sociologists, generic "historians," practicing physicians, or politicians.

Many books and articles have addressed the question of "why?" Objectivity is always the issue in considering history. Who, if anyone, is unbiased? Who is influenced and how much by conflicts of interest? I confess to many biases. I have been an American physician for 65 years (MD 1957); a dues-paying member of the AMA and my respective county, state, and specialty medical societies since the mid-1960s; and I was a full-time AMA employee from 1982 to 1999. After being dismissed by the AMA in 1999, I decided to write my own book Severed Trust: Why American Medicine Hasn't Been Fixed, published by Basic Books (Starr's publisher). It was intended to be a "medical memoir" of what I saw happening to American medicine during my (then) 50 years as an insider.

Ivy Leaguer Peter A. Swenson, Yale C.M. Saden Professor of Political Science, and the Yale University Press now give us Disorder: A History of Reform, Reaction, and Money in American Medicine. Picking up in 1900 with a competing narrative, Swenson bridges the gap to 2022. Between the "bookends" of 1982 and 2021, I found the following books on evolving medical history informative. To celebrate the JAMA Centennial (1883-1983), the book One Hundred Years of JAMA Landmark Articles republished articles exactly as they once were and included a perspective by a current expert about why each was a "landmark" article. These titles provide a history of American clinical medicine and public health.

As another part of the JAMA Centennial, University of Chicago Professor Lester S. King, MD, wrote 24 articles which JAMA published from mid-1982 to mid-1984. Compiled, they became chapters in American Medicine Comes of Age 1840-1920. Dr King subsequently published an expanded version with the Johns Hopkins University Press, titled Transformations in American Medicine, in which King describes the evolution of 18th century physician-theorizing into 19th century medical science. In 1984, AMA employee and historian Frank Campion authored a worthy reference called The AMA and US Health Policy Since 1940.

In a Medscape At Large column in 2017, I lamented "How many books will it take?" while listing nine noteworthy titles that, in aggregate, had not made a dent in the mass problems of the American health "system." I expressed hope that maybe the newest one, Elisabeth Rosenthal's masterful An American Sickness, was powerful and timely enough to be a "tipping point." Alas, no such luck (yet).

After Starr, until now, no one book has succeeded in comprehensively updating, (while somewhat overlapping) Starr's book. Swenson's book is powerful enough to be worth the wait. While Starr's tome spans the years 1780-1982 from the perspective of an academic sociologist, Swenson details years 1900-2021 from the viewpoint of an academic political scientist. These viewpoints differ sharply. I like Swenson's book. It is academic, deeply researched, and liberally annotated. I learned a lot from the insights and comprehensive nature of this book.

For an early clue as to what Swenson's book is about, I looked in the index for "AMA" or "JAMA" and found only two pages. What? So I randomly flipped through scores of pages and found "AMA," "JAMA," or "American Medical Association" mentioned on nearly every page — too many to even index. In contrast, Starr's book references around 100 pages for those words, and flipping through the book reveals those words on many pages, but not nearly as pervasively as in Swenson's book. It would seem that to write about the politics of American medical history, an author must write mostly about the American Medical Association as the political force since 1846, when it was founded. After 1846, the policies and practices of the AMA, for better or worse, have been a focal point of historical medical study. I know from past experience that a lot of Medscape readers love (or at least like or respect) the AMA and what it does; many express hate for the AMA and blame it for all manner of things, with or without validity; and some are neutral, ambivalent, or uncaring.

Swenson's book provides abundant data, dates, names, and nuance about what the AMA (and individuals) actually did and the effects of those actions, from which you may develop a more informed understanding. Swenson is highly regarded in his field and labored long and hard to help the reader understand what has happened to American medicine since 1900 and why. His greatest criticism is that from 1900 to 2021 (especially from 1920 to 1985) the AMA was less about the health of the American people and more about the wealth of the American medical enterprise.

Almost as if anticipating Swenson's book and the serious criticism that the AMA has paid short shrift to the health of the public for much of its history, in November 2021, the AMA's House of Delegates adopted a major report intended to bolster public health. This is great news. The problem is that there is often a giant gap between AMA policy and the implementation thereof, which requires budget, prioritization, approval, and enthusiasm from the internal AMA politicians, be they staff or elected. It bears watching. Some (myself included) might find the timing of this book release by Yale odd. After all, though about as objective as a history book can be, the story it tells is highly critical of much of American medicine. And this at a time when the seemingly endless wheel of COVID has brought out extraordinary and widely lauded medical professionalism, self-sacrifice, even heroism.

But the great arc of American medical history cannot be judged merely through the prism of an ongoing global pandemic, massively disruptive though it be. A 43-page "Epilogue" in Starr's second edition attempts to encapsulate the tumultuous 1982-2016 period, then apologizes for its abrupt ending with Donald J. Trump's election. Notably, in 44 pages he mentions the AMA on only two pages and JAMA on none. Huh? In contrast, Swenson's book references the AMA on every one of the first and last 10 pages. Starr's ultimate characterization of American medicine in 2016 (the final date of his epilogue) as both a national frustration and a national achievement is a compellingly accurate statement.

These books are hugely important reviews of medicine from their disciplines of sociology and politics, but not so much from research, science, clinical practice, technology, pharmaceutical products, diagnostic and therapeutic devices, knowledge dissemination, education, workforce, outcomes, quality of care; even economics and ethics. Swenson seems to be rooting for doctors and the medical profession to serve patients and promote public health, and for AMA politics and leaders to get out of the way.

In trying to figure that out, I learned that Swenson comes from a medical family, both father and a brother being physicians. To me, Starr's book is not at all like that. It's dry, dense, and rich with information and a lot of inside stuff, but it's much more about other dominant social and government organizations and the huge economic drivers of industry. Both Starr and Swenson help readers grasp what has gone on to make the mess, but neither shows us a way out of it.

Starr ends his updating Epilogue with no proposals but merely an observation about national frustration and public distrust that need to be overcome. Swenson closes with a plea for the AMA to revert to earlier public health roots by increasing the number of members, and with that, membership dues as the main source of revenue, replacing its corporate ventures and reliance on industry, and then lobbying transparently toward progressive ends. Not much help, and a pretty grim outlook, despite huge wealth and technologic achievements. That's my opinion. I'm Dr George Lundberg, at large for Medscape.

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